Provider Demographics
NPI:1225088347
Name:SATYAM, DASA
Entity Type:Individual
Prefix:
First Name:DASA
Middle Name:
Last Name:SATYAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1023
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:468 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704-4566
Practice Address - Country:US
Practice Address - Phone:570-718-1307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036767L208VP0014X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009698540011Medicaid
PAB37543Medicare UPIN
PA129493X6JMedicare PIN